name of medication               dose        # of times taken per day

REGISTRATION FORM

Last

First

  Philip Yee MD

Philip Yee  MD

Gastroenterology

PATIENT INFORMATION

Name:

Middle

Marital Status:

Birth Date:

Gender:

SSN:

Driver's License No:

Referring Doctor:

Address:

City

State

Home phone:

Cell phone:

Employer Name:

SPOUSE/PARENT INFORMATION

Name:

Last

First

Middle

Birth Date:

Relationship:

SSN:

Home phone:

Cell phone:

EMERGENCY CONTACT INFORMATION

Name:

Last

First

Relationship:

Contact phone:

INSURANCE INFORMATION

Primary Insurance:

Insurance phone:

Insurance Policy #:

Subscriber Name:

Relationship to patient:

Secondary Insurance:

Insurance phone:

Insurance Policy #:

Subscriber Name:

Relationship to patient:

HEALTH QUESTIONAIRE

Reason for  office visit:

1. History of Past Illness:

Prior Surgery/ Hospitalization:

Current Medication taken:

2. Family History:

3. Social / Personal History:

Drinking alcohol:

Smoking:

Occupation:

Allergies:

4. System Review:

Height:

Weight:

I agree to the HIPAA policy and office policies and I am financially responsible for all charges for services to me, including balance remaining after payment of possible insurance benefits and for services not covered by my insurance.

I authorize payment of medical benefits to myself or the names provided for professional services rendered.

I authorize the release of any medical information necessary to process this claim.

I request that medical information may be left at my telephone voice mail.

- Telephone #:

Signature : ____________________________        Date :  __________

Print Name

Race:

Language:

Ethnicity:

information required by US Dept of Health & Human Svc. CMS mandate:

Subscriber SSN:

Please mark all applicable box(es) below .

drug    &    reaction:

last pneumovax?

last flu vaccine?

please list details...

Due to HIPAA rules we canot accept electronic transfer of information at this time. 

Please print, sign and fax to 925-275-1814.  Thank you.

Valley Digestive Care

if not patient,

state relationship:

Male         Female     

PPO       HMO    

none

none

GI disorders (cancer, polyp, etc)

other

neverpreviously smoked  presently smoking       

yes
no

--select one--AsianBlack or African AmericanDecline to AnswerNative Hawaiian or Pacifc IslanderMexican Indian or Alaska NativeOther RaceWhite

--select one-EnglishSpanishArabicBengaliCantoneseChinese MandarinFarsi (Persian)FrenchGermanHindiItalianJapaneseKannadaKoreanMalay, IndonesianMarethiOtherPolishPortuguesePunjabiRussianTamilTeluguThaiTurkishUrduVietnameseWu

--select one--Decline to AnswerHispanic or LatinoNot Hispanic or Latino

weight change

trouble swallowing

heartburn

nausea

vomiting

ulcers

Abdominal pain

Gall bladder disease

Liver disease

Pancreas disease

Constipation

Diarrhea

Colitis or Crohns disease

Diverticulosis

Colon polyp

Changed bowel habits

Blood in stool

Hemorrhoids

Anal fissure or fistula

Skin disease

Cough

Asthma

Arrhythmia

Heart trouble

High blood pressure

Heart murmur:

Valvular heart disease

Burning urination

Kidney trouble

Arthritis

Back pain

Headache

Seizures

Anemia

Thyroid disease

High cholesterol

Diabetes

no drug allergy

singlemarriedother          

PPO      HMO     

neverrarelymoderately